CHAPTER 4

GAF EQUIVALENT AND

DANGEROUSNESS LEVEL

4–1
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 GAF Equivalent and Dangerousness Level 4–3

GAF EQUIVALENT AND DANGEROUSNESS LEVEL

CONTENTS

I. Overview ......................................................................................................................................... 4–5

II. GAF Equivalent ................................................................................................................................ 4–5
III. Dangerousness Level ....................................................................................................................... 4–6
A. Weighted Dangerousness Level Scores ........................................................................................ 4–7
B. Using the Dangerousness Level to Screen for Admission.............................................................. 4–7
C. Unweighted Versus Weighted Scores .......................................................................................... 4–8
IV. Dangerousness Level and the GAF Equivalent................................................................................ 4–8
V. Determination of the GAF Equivalent and Dangerousness Level Scores........................................ 4–9
VI. Number of Subscales Needed to Determine the Dangerousness Level ....................................... 4–13
VII. References ..................................................................................................................................... 4–13
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 GAF Equivalent and Dangerousness Level 4–5

GAF EQUIVALENT AND DANGEROUSNESS LEVEL

I. Overview
As pointed out in Chapter 1, Section II: “Comparison of the K Axis to the GAF,” an equivalent to the
GAF should address at least two factors: 1) psychiatric symptoms and 2) level of functioning. This is
done with the GAF Equivalent and the Dangerousness Level. Descriptions of the GAF Equivalent and
Dangerousness Level and how to derive them follow. Also, this chapter provides an explanation as to
how these measures can work together to better reveal the factors that the GAF currently must convey
with a single number.

II. GAF Equivalent

The Psychological Impairment and Violence subscales address mostly psychiatric symptoms and the
Social Skills and ADL–Occupational Skills subscales address mostly level of functioning. Adding these
first four subscales and dividing by 4 generates the GAF Equivalent. This method should give a score
that is roughly equivalent to the GAF. However, unlike the GAF, the GAF Equivalent can ensure that the
major areas of functioning are not overlooked and that some details of its generation are available.
Only the first four subscales are used to determine the GAF Equivalent because these are the
subscale areas that are addressed by the GAF. The GAF does not measure Substance Abuse, Medical
Impairment, or Ancillary Impairment; therefore, these three subscales are not used to determine the
GAF Equivalent. By including the first four subscales, the GAF Equivalent provides a comprehensive
global assessment of functioning, while at the same time acting as an estimate of the GAF.
In the calculation of the GAF Equivalent, it is assumed that the four subscales are equally
important. Therefore, each of the four subscales is given equal weight when determining the GAF
Equivalent. Some may argue that Psychological Impairment and Violence should be given more weight;
however, others argue that the current system works very well because it ensures that level-of-
functioning factors are included in a rating that is supposed to capture level of functioning, not just
psychiatric symptoms.
Clinically, the method used to determine the GAF Equivalent appears to generate a reasonably
accurate equivalent to the GAF, and it does so without having to employ a complicated weighting
system. Additional support for the GAF Equivalent comes from the California Outcome Measures
Project (Higgins and Purvis 2000), which examined the correlation between the GAF and the GAF
Equivalent. This project found the correlation to be 0.82. The California Outcome Measures Project also
revealed that the GAF and the GAF Equivalent had significant correlations with the individual subscales
of the K Axis. See Table 4–1 for details on these findings (this table is also presented in Chapter 2). The
mean scores for the clients in the sample are also shown in Table 4–1.

Table 4–1. Correlation coefficient between the K Axis

and GAF (California Outcome Measures Project)
GAF Mean
Measure GAF Equivalent score
GAF 1.00 0.82 57
GAF Equivalent 0.82 1.00 64
Psychological Impairment 0.86 0.83 56
Social Skills 0.72 0.85 61
Violence 0.50 0.74 78
ADL–Occupational Skills 0.64 0.84 62
Substance Abuse 0.27 0.29 82
Medical Impairment 0.19 0.21 76
Note. All correlations were statistically significant (P < 0.01).
4–6 Mastering the Kennedy Axis V

The subjects in the California Outcome Measures Project were outpatients with a fairly low
incidence of violent behaviors; therefore, as expected, both the GAF and the GAF Equivalent had a
relatively high correlation with Psychological Impairment (0.86 and 0.83, respectively). Because of the
low incidence of violence in this population (average rating on the Violence subscale was 78) and the
relatively high incidence of psychological impairment (average rating on the Psychological Impairment
subscale was 56), the GAF was most likely measuring psychological impairment rather than violence.
Therefore, the correlation between the GAF and the Violence subscale is relatively poor (0.50). If the
subjects had been very violent, the GAF would have had a higher correlation with the Violence subscale
and possibly a much lower correlation with the Psychological Impairment subscale.
Because the GAF does not measure substance abuse or medical impairment, there was an expected
low correlation between the GAF and both the Substance Abuse and Medical Impairment subscales
(0.27 and 0.19, respectively). The same low correlation is true for the GAF Equivalent, which also does
not measure substance abuse or medical impairment (correlations of 0.29 and 0.21, respectively).
Probably the closest true equivalent to the GAF using the K Axis would be obtained by taking the
most impaired score from two subscales: 1) Psychological Impairment and 2) Violence. Of the subscales,
Psychological Impairment has been shown to have the highest correlation with the GAF; however, the
patient sample used for this determination was composed of patients who had relatively few problems
in the subscale area of Violence. A mean rating of 78 on the Violence subscale revealed this. Conversely,
it is speculated that in a very violent population, the Violence subscale would probably be more
reflective of a true equivalent to the GAF than the Psychological Impairment subscale. Therefore, both
measures would be needed to determine the most accurate GAF Equivalent and that equivalent would
be determined by selecting the rating that reflects the most dysfunctional score for these two subscales.
Such an equivalent to the GAF that uses only the Psychological Impairment and Violence subscales
may more accurately capture the GAF. However, this method of determining the GAF Equivalent is not
recommended because the GAF Equivalent is intended to improve on the GAF’s ability to capture level
of functioning, including capturing a client’s skills.
In some situations, for a purer measure of level of functioning, you may want to omit the Violence
subscale rating and possibly the Psychological Impairment rating from the calculation of the GAF
Equivalent. This would be especially true if the population being measured has very high levels of
violence. The high levels of violence could easily obscure skills and other areas of functioning.

III. Dangerousness Level

The GAF Equivalent measures average level of functioning across the first four subscales. However, to
get a fuller picture of what the GAF is measuring, you also need a measurement that captures specific
declines in functioning or the presence of severe psychiatric symptoms. The greater these declines are,
the more likely they are to be associated with dangerous levels of functioning or dangerous behaviors.
Because these declines are often associated with dangerousness, the measurement that captures these
declines is called the Dangerousness Level. As its name indicates, it captures dangerousness, including
violence. The addition of this measure gives the K Axis the power to sweep through the subscales to
uncover any significant area of dangerousness. These significant areas of dangerousness can also be a
key factor in the determination of the GAF.
The Dangerousness Level is a measure that can be used to determine the most dangerous rating
reached by the K Axis subscales. Chapter 3, Section VI: “Dangerousness,” pointed out that
dangerousness is a part of each of the subscales. The Dangerousness Level is a measurement derived
from the subscales and represents the maximum severity of dangerousness measured by the subscales
(i.e., the most severe psychiatric symptoms or impairment in skills). By helping to indicate how
dangerous a patient is, the Dangerousness Level can be a powerful clinical indicator. For example, it
could be used as an adjunct to screen for patients who may require high-intensity outpatient care, a
residential program, or even hospitalization.
The Dangerousness Level must address the first four subscales to capture what the GAF is
measuring. Because the Dangerousness Level can go beyond the first four subscales, it can expand the
measurement of dangerousness beyond what is measured by the GAF. Some clinicians may find the
Dangerousness Level more useful if Medical Impairment and Ancillary Impairment are not included in
 GAF Equivalent and Dangerousness Level 4–7

the determination of the Dangerousness Level. This will be addressed later in Section VI: “Number of
Subscales Needed to Determine the Dangerousness Level.”
In certain clinical situations, the Dangerousness Level may be more representative of the GAF than
the GAF Equivalent. This is often seen when a particular GAF rating reflects violence or other dangerous
behaviors seen in only one or two of the first four subscales, whereas the client has relatively few
problems in the other subscale areas. This would be demonstrated in the example of the severely
suicidal college professor who functions very well in the areas of Social Skills and ADL–Occupational
Skills; however, these skills would falsely elevate the GAF Equivalent score when compared with the
GAF. This GAF Equivalent score would give the impression that the GAF score is better than it actually
is; however, the Dangerousness Level would capture the poor score in the Violence subscale and would,
therefore, more accurately reflect the GAF.

A. Weighted Dangerousness Level Scores

Based on years of clinical experience and use of the K Axis, weighted Dangerousness Levels have been
set across all of the seven subscales. These are empirical determinations. They were set so that
Dangerousness Level scores of 50 or lower could be used as a general guideline to indicate a very
significant level of dangerousness for each subscale. These low scores are often associated with the need
for high-intensity outpatient care, a residential program, or even hospitalization. The weighted
Dangerousness Level scores are automatically determined when rating the K Axis subscales. Details on
how this is done are presented later in this chapter in Section V: “Determination of the GAF Equivalent
and Dangerousness Level Scores.”
The weighted Dangerousness Level scores were not based on statistical correlations of K Axis scores
with actual dangerous outcomes. They were empirical determinations; however, it is believed that these
empirically determined Dangerousness Level values have significant face validity. Even with a formal
study, the final, weighted scores may be at or very close to their current values. In the future, the
validity of the Dangerousness Level should be tested in a more scientific manner.

B. Using the Dangerousness Level to Screen for Admission

Dangerousness Level ratings that reach 50 or lower are often associated with the need for high-intensity
outpatient care, residential care, or even hospitalization. Certainly one of the most important decisions
concerning dangerousness is whether a patient should be admitted. Whether a patient has reached a
Dangerousness Level score of 50 or lower may help determine whether the patient should be admitted.
In most high-intensity treatment programs, most patients, if not all, would be expected to have a
Dangerousness Level of 50 or lower. You may want to explore the appropriateness of admissions to
high-intensity treatment programs of patients with a Dangerousness Level score significantly higher
than 50. As stated in the following warning statement, be careful not to put too much emphasis on a
single measure when making clinical decisions or when reviewing clinical decisions.

WARNING
Clinicians are strongly discouraged from using the K Axis scores alone, including the Dangerousness Level score, to
make complicated clinical decisions, such as decisions related to admission or discharge. The ability of the K Axis
scores to be used alone for complicated clinical decisions is very hypothetical (i.e., there is little scientific or clinical
evidence to support such use). Therefore, K Axis scores should not be used alone, especially for such vital clinical
decisions. There should be a narrative description of the patient’s symptoms and behaviors that supports any decision
made. Often the clinical information included in the problem description section of the scoring sheet can be used to
satisfy this need. The use of similar narrative summaries in such decisions is, of course, common clinical practice.
Based on such summaries, the clinician is often able to communicate whether certain decisions should be made or
whether additional information is needed. These issues are addressed in Chapter 1, Section VIII: “K Axis and Clinical
Decisions,” and in Chapter 5, “Problem Description Section of the Scoring Sheet.” This is also addressed in the
“Cautionary Note” at the beginning of this book.
4–8 Mastering the Kennedy Axis V

A Dangerousness Level of 50 or less can be a good rule of thumb to indicate the need for high-
intensity treatment. However, because various programs are able to handle different levels of
functioning in patients, a Dangerousness Level score of 50 may not match the specific admission
criteria of every agency. Therefore, use Dangerousness Levels that fit the particular needs of your
agency. Again, it cannot be overemphasized that the Dangerousness Levels must only be a part of a
more elaborate admission screening process.
The concept of the Dangerousness Level as a screening tool for admission is complicated by the
fact that a particular Dangerousness Level score can be seen as a justification for admission by some
agencies or treatment groups. However, the same Dangerousness Level may be seen as an admission
barrier in other agencies or treatment groups. For example, an outpatient support group for patients
with mild depression may not be capable of handling patients with a Dangerousness Level of 50 or
lower, especially if the Dangerousness Level is due to ratings on Psychological Impairment or Violence.
Therefore, such a score may be a barrier to acceptance into that group.

C. Unweighted Versus Weighted Scores

The weighted scores used to determine the Dangerousness Level are intended to search across the
subscales to locate the most dangerous level within the subscales. In all other uses of the K Axis, you
should use the unweighted scores. When you are not comparing dangerousness across subscales,
converting to the weighted scores may simply lead to unnecessary complications and confusion.
Therefore, when focusing on dangerousness in fewer than the first four subscale scores, it may just
complicate the process to convert to the weighted dangerousness scores. The unweighted K Axis scores
should work just as well as the weighted scores in such situations. Any advantage that is gained would
likely be offset by the added complication of using the weighted scores.
Therefore, when you are not screening through at least the first four weighted subscales for the
most dangerous rating, an individual K Axis subscale score or combination of the scores should be used.
In this situation, the Dangerousness Level would not be used because you would not be screening
through at least the first four weighted subscales for the most dangerous rating. Simply use the
unweighted subscale score(s) rather than converting them to scores weighted for dangerousness. For
example, a program may be designed to specialize in the treatment of socially impaired schizophrenic
patients who also have significant problems with occupational skills. The admission criteria may be that
the patients have a diagnosis of schizophrenia and a K Axis score of 50 or worse in the subscale area
Social Skills and 40 or worse in the subscale area ADL–Occupational Skills. There would be no reason to
convert the score to a weighted dangerousness score.
Similarly, if this program is unable to manage patients who are very violent, the program’s
admission criteria may require that patients not have low scores in the K Axis subscale for Violence. In
these cases, you are not simply screening for the most dangerous rating across the subscales. Using the
weighted dangerousness scores is unnecessary and may only create confusion; therefore, use the K Axis
unweighted scores from the relevant subscales.
In summary, the Dangerousness Level is a screening tool, and the individual weighted subscale
scores are not intended to replace the individual unweighted K Axis subscale scores. If you are trying to
screen for dangerousness across most of the subscales, then it may be best to convert the scores to a
Dangerousness Level score. However, you should certainly not use the Dangerousness Level score when
the K Axis unweighted score(s) can work just as well or even better.

IV. Dangerousness Level and the GAF Equivalent

One of the major roles of the Dangerousness Level is to ensure that a relatively high GAF Equivalent
score does not obscure very low functioning in one of the other subscale areas.
If the GAF rating is at the high end of the continuum, the GAF Equivalent and Dangerousness
Level are probably both highly correlated with the GAF rating. At the lower end of the continuum, if
the GAF is continuing to measure level of functioning, the GAF Equivalent should continue to be
highly correlated with the GAF. However, if the GAF is measuring violence, then the Dangerousness
 GAF Equivalent and Dangerousness Level 4–9

Level may be much more highly correlated with the GAF. In other words, at the more dysfunctional
end of the GAF continuum, in addition to measuring level of functioning, the GAF increasingly
measures violence to self and others. Therefore, it is unclear whether very dysfunctional GAF scores are
due to poor level of functioning or very violent behaviors. Marked violence can obscure true level of
functioning at the low end of the GAF (e.g., the seriously suicidal banker may score the same on the
GAF as a chronic, inpatient schizophrenia patient who has been unemployable for decades, though
obviously they have very different levels of functioning).
The K Axis attempts to deal with this problem by allowing the GAF Equivalent and the
Dangerousness Level to work together. In the example of the suicidal banker and the patient with
chronic schizophrenia, both patients may have the same Dangerousness Level score, that is, the banker
may have a 20 due to his very real danger of hurting himself and the schizophrenic patient may have a
20 due to his gross impairment in thinking and communication. However, the GAF Equivalent for the
banker may be around 65, which is significantly better than the GAF Equivalent for the chronic,
inpatient schizophrenic patient, which may be around 40. Without the Dangerousness Level, the
banker’s high scores in the areas of Social Skills and ADL–Occupational Skills can obscure the fact that
the banker is extremely suicidal and in much greater need of care than a GAF Equivalent score of 65
would suggest.
The GAF Equivalent should give a good overview of the patient’s level of functioning by providing
an average of the key clinical areas addressed by the GAF, including violence. The Dangerousness Level
screens for a significant drop in functioning in one of the subscale areas, including all of the subscales
addressed by the GAF. The GAF Equivalent score should be very helpful in screening for impaired level
of functioning and serious psychiatric symptoms. The Dangerousness Level can act in conjunction with
the GAF Equivalent score to ensure that areas of high functioning do not cover up an area or areas of
significant impairment. These areas of low functioning can be associated with very dangerous outcomes
and certainly should not be missed. Therefore, the Dangerousness Level, which captures any declines in
functioning, may be just as useful as the GAF Equivalent when attempting to generate an equivalency
to the GAF.

V. Determination of the GAF Equivalent and Dangerousness Level Scores

The GAF Equivalent is based on the first four subscales. The Dangerousness Level can be calculated
using all seven subscales; however, some programs may find the Dangerousness Level more useful if
specific subscales, such as Medical Impairment and Ancillary Impairment, are not included in the
determination of the Dangerousness Level. Regardless of the number of subscales chosen to determine
the Dangerousness Level, a similar method is used to calculate the actual Dangerousness Level rating. In
the examples given below, the calculations were done on full sets of seven subscales. The GAF
Equivalent was usually calculated first, then the Dangerousness Level; however, it does not matter
which is calculated first.
The GAF Equivalent is the average score for the first four subscales (Psychological Impairment,
Social Skills, Violence, and ADL–Occupational Skills). To calculate the GAF Equivalent, simply add these
subscale ratings, divide by 4, and then round off to the nearest multiple of 5, as shown in Figure 4–1.
4–10 Mastering the Kennedy Axis V

Subscale Score used

Subscale score to derive DL
Psychological Impairment 40 55
Social Skills 55 65
Violence 70 70
Substance Abuse 65 75
ADL–Occupational Skills 80 80
Medical Impairment 70 75
Ancillary Impairment 80 80
DL = Dangerousness Level.

GAF Equivalent Score

#1 40 + #2 55 + #3 70 + #4 65 = 230 / 4 = 57.5 = 60

Figure 4–1. Example of the determination of the GAF Equivalent.

In the example in Figure 4–1, the 60 represents 57.5 rounded to the nearest multiple of 5. The GAF
Equivalent would be 60. This is calculated by adding 40, 55, 70, and 65, which equals 230. Next step is
dividing by 4, which equals 57.5. Rounding to the nearest multiple of 5 equals 60. The Dangerousness
Level for the K Axis is the lowest weighted score for at least the first four subscales. Once you have the
weighted scores, the actual determination of the Dangerousness Level is almost instantaneous;
therefore, in the example in Figure 4–1, the Dangerousness Level would be 55 because it is the most
dangerous rating of the scores used to calculate the Dangerousness Level. In other words, determining
the Dangerousness Level takes only two steps:

1. First, determine the weighted scores used to calculate the Dangerousness Level. This is
determined automatically, as follows in Step 2.
2. Next, simply choose the lowest score determined in the first step. This score becomes the
Dangerousness Level.

In Figure 4–1, the weighted score was already calculated for you; however, the calculation of these
weighted scores is extremely easy because it is totally automatic. Once you have rated all the subscales
on the scoring sheet, the weighted scores used to determine the Dangerousness Level are the scores
directly below the corresponding subscale score. This is illustrated as follows for Psychological
Impairment:

ÄÄ FUNCTIONAL DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100 95 90 90 85 80 75 75 70 70 65 60 55 55 50 40 35 25 15 5

The lower row of numbers are the scores used to determine the Dangerousness Level. As you can
see, once the subscale is rated, the scores used to determine the Dangerousness Level are automatically
indicated below the subscale ratings. The lowest of these scores becomes the Dangerousness Level. For
example, a subscale score of 55 on the Psychological Impairment subscale would be indicated by placing
an X in the blank following the subscale score of 55, as follows:
 GAF Equivalent and Dangerousness Level 4–11

ÄÄ FUNCTIONAL DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 X 50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100 95 90 90 85 80 75 75 70 70 65 60 55 55 50 40 35 25 15 5

The subscale score for Psychological Impairment, marked by the X, is 55. The Psychological
Impairment score used to determine the Dangerousness Level is located just below the subscale score;
that score is 70.
If the Psychological Impairment subscale score had been 65, the score used to determine the
Dangerousness Level score would be 75. If it had been 90, the score to determine the Dangerousness
Level would be 90, if 30, the score would be 50, and so on. Next, repeat this for each of the seven
subscales or for all the K Axis subscales that you plan to use in your determination of the Dangerousness
Level.
Once you have completed rating the K Axis subscales, the scores used to derive the Dangerousness
Level will be directly below the subscale scores. Simply select the lowest of these scores and it becomes
the Dangerousness Level for the K Axis.

Subscale Score used

Subscale score to derive DL
Psychological Impairment 55 70
Social Skills 75 80
Violence 25 25
Substance Abuse 80 85
ADL–Occupational Skills 90 90
Medical Impairment 80 85
Ancillary Impairment 80 80
DL = Dangerousness Level

GAF Equivalent Score

#1 55 + #2 75 + #3 25 + #4 80 = 235 / 4 = 58.75 = 60

Figure 4–2. Example of the determination of Dangerousness Level.

The Dangerousness Level for the K Axis in Figure 4–2 would be the most dangerous rating from the
row used to derive the Dangerousness Level (i.e., 25). This Dangerousness Level score of 25 for the
K Axis would indicate that this patient is very impaired in at least one subscale area. The GAF
Equivalent for this example would be 60.
The 60 represents 58.75 rounded off to the nearest multiple of 5. This is calculated by adding 55,
75, 25, and 80, which equals 235. Next divide by 4, which equals 58.75. Rounding to the nearest
multiple of 5 equals 60. Without the Dangerousness Level score of 25, the relatively high GAF
Equivalent of 60 would hide the fact that the patient had some very serious problems in at least one
subscale area.
4–12 Mastering the Kennedy Axis V

In the next example (Figure 4–3), the GAF Equivalent of 85 and Dangerousness Level of 85 reveal
that the client should be relatively healthy.

Subscale Score used

Subscale score to derive DL
Psychological Impairment 85 90
Social Skills 80 85
Violence 90 90
Substance Abuse 90 90
ADL–Occupational Skills 90 90
Medical Impairment 80 85
Ancillary Impairment 85 85
DL = Dangerousness Level.

GAF Equivalent Score

#1 85 + #2 80 + #3 90 + #4 90 = 345 / 4 = 86.25 = 85

Figure 4–3. Example of the determination of Dangerousness Level.

The GAF Equivalent of 85 represents 86.25 rounded off to the nearest multiple of 5. This is
calculated by adding 85, 80, 90, and 90, which equals 345. Next divide by 4, which equals 86.25.
Rounding to the nearest multiple of 5 equals 85. In this case, the GAF Equivalent supports what the
Dangerousness Level score of 85 revealed, that is, this person is probably fairly healthy. In this case, the
relatively high GAF Equivalent was not hiding any serious problems in any of the subscale areas.
The Dangerousness Level for the K Axis in Figure 4–3 would be the most dangerous rating from the
column used to derive the Dangerousness Level (i.e., 85). This Dangerousness Level score of 85 for the
K Axis indicates that the patient probably has no serious problems in any of the subscale areas. Even
without the GAF Equivalent, you know that this person with a Dangerousness Level score of 85 is
probably fairly healthy; however, the GAF Equivalent helps to confirm that the person is doing well.
For three of the subscales (Violence, Substance Abuse, and Ancillary Impairment), no weighting is
necessary to determine the Dangerousness Level. Therefore, scores used to determine the Dangerousness
Level are identical to the subscale scores in these three subscales. For example,

3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5

In the Violence subscale, a score of 55 would indicate a score of 55 for use in determining the
Dangerousness Level. A score of 90 would indicate a score of 90 for use in determining the
Dangerousness Level, and a score of 65 would indicate a score of 65 for use in determining the
Dangerousness Level.
In the other four subscales (Psychological Impairment, Social Skills, ADL–Occupational Skills, and
Medical Impairment), the scores used to derive the Dangerousness Level have to be weighted so that
they better reflect the level of dangerousness along the continuum. The weighted scores reflect the fact
that a lower subscale score is needed to represent the equivalent level of dangerousness in the other
three subscales. For example, a score of 50 in the Violence subscale is felt to indicate more
dangerousness than a score of 50 in Psychological Impairment. Therefore, the score used to derive the
 GAF Equivalent and Dangerousness Level 4–13

Dangerousness Level in Psychological Impairment has been weighted. The resulting weighted score is
30 for a Psychological Impairment subscale score of 50 (i.e., a K Axis score of 50 on Violence is felt to
indicate as much dangerousness as a K Axis score of 30 on Psychological Impairment). In other words, a
patient has to be more impaired in the areas of Psychological Impairment, Social Skills, ADL–
Occupational Skills, and Medical Impairment than in the areas of Violence, Substance Abuse, and
Ancillary Impairment to be considered at the same level of dangerousness.

VI. Number of Subscales Needed to Determine the Dangerousness Level

Because rating Ancillary Impairments is optional, consideration should be given to using no more than
the first six subscales in the determination of the Dangerousness Level. As the Dangerousness Level
evolves through clinical use, it may come to represent only the first five subscales. This would also
eliminate Medical Impairment from the determination of the Dangerousness Level. The dangerousness
related to Medical Impairment may not be as relevant to clinical psychiatric decisions and the Ancillary
Impairment subscale, which is optional, may not even be completed; therefore, their inclusion may just
cloud the findings of the other subscales. If subscales 1 through 5 are used to determine the
Dangerousness Level, this may be referred to as the Dangerousness Level Basic or the Dangerousness
Level 1–5 (DL Basic or DL 1–5). Eventually, Dangerousness Level may become synonymous with the DL
Basic. If all seven subscales have been used, this might be referred to as the Dangerousness Level Plus or
Dangerousness Level 1–7 (DL Plus or DL 1–7).
You may limit the determination of dangerousness to be derived from only the first four subscales
(Psychological Impairment, Social Skills, Violence, and ADL–Occupational Skills). These first four
subscales are the areas addressed by the GAF. It is strongly recommended that no fewer that the first
four subscales be used in your determination of the Dangerousness Level. If the first four subscales are
used to determine the Dangerousness Level, this might be indicated as the Dangerousness Level 1–4 (DL
1–4).
If the rater fails to rate the required subscales and a Dangerousness Level rating is needed, the rater
should rate the Dangerousness Level based on the available subscale scores rather than leaving the
Dangerousness Level blank. In such a case, if possible, the rater should indicate exactly which subscales
the rating is based on (e.g., Dangerousness Level 1, 3, and 5).
If you are not screening for the most dangerous rating across at least the first four subscales, it is
recommended that you probably not use the weighted Dangerousness Level scores. When using fewer
than the first four subscales, it is best to use the unweighted K Axis scores and to not calculate a
Dangerousness Level.

VII. References
Higgins J, Purvis K: A Comparison of the Kennedy Axis V and the Global Assessment of Functioning Scale. Journal
of Psychiatric Practice 6(2):84–90, 2000
Notes